Basic Information
| Provider Information | |||||||||
| NPI: | 1972997724 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLADEINDE | ||||||||
| FirstName: | ROBERT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 E OLNEY AVE | ||||||||
| Address2: | STE 400 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191202470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4109991129 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5501 OLD YORK RD STE 3 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191413018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2154567180 | ||||||||
| FaxNumber: | 2154567052 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2015 | ||||||||
| LastUpdateDate: | 08/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | C05740 | MD | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207V00000X | MD473152 | PA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1033252630001 | 05 | PA | MEDICAID |